pressure to perform c-sections?

[epsilonprodigy]

I may be opening a can of worms here, but I'm curious: current residents and practicing OB's, would you say that you feel undue pressure to perform c-sections? If so, what is the origin (financial, institutional policy or concerns about risk management/malpractice?) How often do you feel that c-sections are performed when they could safely be avoided?

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[anonperson]

I may be opening a can of worms here, but I'm curious: current residents and practicing OB's, would you say that you feel undue pressure to perform c-sections? If so, what is the origin (financial, institutional policy or concerns about risk management/malpractice?) How often do you feel that c-sections are performed when they could safely be avoided?

Where does this common misconception that OBs and hospital administrators somehow desire more Cesarean deliveries?

Our C/D rate is on the higher side at around 30% mainly due to being a referral center for high risk obstetrics but in reality, if an attending is significantly higher than this, the administration is going to address this as it is generally considered a negative.

At least where I'm at, the OBs would much rather prefer an uncomplicated vaginal delivery versus a C/D. Less hospital rounding, less need for an office follow up for a staple removal/wound check, less complications.

C/Ds are high for numerous reasons, but hospital admins are not pushing it as far as I am aware of.

 

[epsilonprodigy]

This is nice to hear. I meant no disrespect: I am a lowly MS-1 ;-) and don't have much to go on besides 60 minutes and anecdotes. I often think that I may enjoy OB, but feeling pushed to do c-sections solely to cover my butt would be a deal-breaker for me. I hope the attitude you speak of is similar at my institution.

 

[DoctwoB]

This is nice to hear. I meant no disrespect: I am a lowly MS-1 ;-) and don't have much to go on besides 60 minutes and anecdotes. I often think that I may enjoy OB, but feeling pushed to do c-sections solely to cover my butt would be a deal-breaker for me. I hope the attitude you speak of is similar at my institution.

Section rates are high for a lot of reasons: A lot of patients want them. High rates of obesity/comorbidities making lots of higher risk deliveries. The fact that VBACs are higher risk, etc. Doing a c-section will hardly cover your butt anyways. Complications rates are higher for sections, and you can be sued regardless of whether its a complication of c-section or vaginal birth.

 

[BabyCatcher2012]

At least where I'm at, the OBs would much rather prefer an uncomplicated vaginal delivery versus a C/D. Less hospital rounding, less need for an office follow up for a staple removal/wound check, less complications.

Agreed. It's rare that I see a purely elective c/s. One of the MFM presents the hospital statics at M&M each month and they make a big deal about reducing elective inductions and sections.

One area where there is significant variation is VBAC- some docs are more comfortable with VBAC, while others will encourage repeat c/s.

 

[rph3664]

This piece aired on NPR this morning. In short, wealthy Brazilian women who patronize private hospitals generally have a c-section rate exceeding 90% , in part because of a "too posh to push" movement. For one thing, I wonder just how informed the consent they receive really is, and if they think that childbirth is inconvenient, just wait until they have to actually take care of that baby.

http://www.npr.org/2013/05/12/182915406/c-sections-deliver-cachet-for-wealthy-brazilian-women

I never had kids, but I've been told many times that no sane woman would choose to have a baby that way. I'm also very aware that the unnecessary c-section debate has been going on since the 1840s, when surgical anesthesia made the procedure feasible on a live woman.

 

[epsilonprodigy]

This is very sad, and in my opinion, probably reflects these doctors sacrificing patient education to improve the quality of their own schedules.

Peripherally-related: what do you do when a patient who refuses to get a Foley but needs a c-section? I imagine this must be a pretty common problem. I actually read a couple of articles saying that going without leads to sooner post-op ambulation and fewer complications overall, but as far as I know, most hospitals still use them.

Thoughts?

 

[anonperson]

Peripherally-related: what do you do when a patient who refuses to get a Foley but needs a c-section? I imagine this must be a pretty common problem. I actually read a couple of articles saying that going without leads to sooner post-op ambulation and fewer complications overall, but as far as I know, most hospitals still use them.

Thoughts?

Tell them they're being obstructive in their own care and quit being stupid. Yeah a C-section is fairly routine and you could probably get away with no foley in a majority of cases if they finished in under an hour, but what happens when **** hits the fan and you end up with extra bleeding, c-hyst, extensive adhesions on a repeat etc.

Besidse, most patients have spinals and aren't able to walk post operatively for a little bit of time and effectively void. The only other alternative I could think of is scheduled straight cathing which is probably more bothersome at that point.

 

[epsilonprodigy]

Sorry, should have specified: I meant patients who refuse to be cath'd in general (straight or Foley.) A friend asked about this recently and I found that I didn't know.

 

[THP]

I have never once been pressured to perform a c/s. In fact, I think the opposite is true, there is almost too much pressure to get a vaginal delivery, when a lot of times a c/s is warranted.

A couple related points:

1. There is no such thing as an unnecessary c/s in my opinion. How would you ever know it was not needed. The point of doing a c/s is to get a good outcome.

2. I will do a primary c/s on maternal request as long as she understands the risks. I will try and discourage her from it if she wants 3 or more kids.

3. We have no idea what the c/s rate should be.

4. I'm getting close to finishing my first year out of residency and my primary c/s rate is about 20.6% so far.

 

[THP]

Section rates are high for a lot of reasons: A lot of patients want them. High rates of obesity/comorbidities making lots of higher risk deliveries. The fact that VBACs are higher risk, etc. Doing a c-section will hardly cover your butt anyways. Complications rates are higher for sections, and you can be sued regardless of whether its a complication of c-section or vaginal birth.

You are less likely to get sued from a complication of a procedure because that rarely involves malpractice. Known complications do occur. The obstetric lawsuits are almost always failure to perform a timely c/s because that involves your decision making process. The best way to ensure a good outcome for a newborn is through an elective c/s at 39 weeks. The problem is you would have to do a lot of c/s to prevent one bad outcome and exposing moms to lots of surgery and the inherent risks and higher complication rates.